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STATE OF NORTH CAROLINA RFP No. 30-DMA-284-11 REQUEST FOR PROPOSALS TITLE: Reviews of Emergency Medicaid Services Provided to Aliens USING AGENCY: NC DHHS, Division of Medical Assistance ISSUING AGENCY: N.C. Department Of Health and Human Services Office of Procurement and Contract Services Raleigh, NC 27603 ISSUE DATE: May 26, 2011 SUBMISSION DATE: June 30, 2011 Inquiries: Direct all inquiries regarding this Request for Proposals (“RFP”) to: Office of Procurement and Contract Services Telephone: (919) 855-4095 Kathy Domico 801 Ruggles Drive, Hoey Building Facsimile : (919) 733-5957 Raleigh, NC 27603 e-mail : email@example.com Notice To Vendors: The requirements of this RFP can only be altered by written addendum. Verbal communications shall not be binding upon the State. Written Questions: All written questions regarding this RFP must be submitted via e-mail to Kathy.firstname.lastname@example.org no later than 2:00 pm on June 13, 2011. The State will not respond to questions submitted thereafter. A summary of all questions and answers regarding this RFP will be posted within approximately five (5) business days on the State’s Interactive Purchasing System (IPS) web site at http://www.ips.state.nc.us/ips/pubmain.asp .The written questions and answers posted on this web site shall constitute an addendum to this RFP. Submission Deadline: Sealed proposals, subject to the conditions made a part hereof, will be received until 2:00 p.m. Eastern Standard Time on the day of opening and then opened, for furnishing and delivering the commodity/service as described herein. Submission Instructions: Submit two (2) originals and five (5) copies of the Proposal. Submit all copies of the Technical Proposal in one sealed package and all copies of the Cost Proposal in a separate sealed package. Clearly mark each package with: (1) the Vendor’s name; (2) the RFP number; (3) the submission date shown above; and (4) the words “Technical Proposal” or “Cost Proposal” as appropriate. Address the packages for delivery as shown below. Proposals may be submitted by U.S. Mail, common carrier, or hand delivery. Vendor must also submit two (2) electronic copies of its proposal on read-only CD/DVD(s). The files on the discs should not be password-protected and should be capable of being copied to other media. . Proposals may not be submitted by electronic means. IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS RFP NO. 30-DMA-284-11 RFP NO. 30-DMA-284-11 Attn: Kathy Domico Attn: Kathy Domico NC Dept Health & Human Services NC Dept Health & Human Services Office Of Procurement & Contract Services Office Of Procurement & Contract Services 2008 Mail Service Center 801 Ruggles Drive, Hoey Building Raleigh, NC 27699-2008 Raleigh, NC 27603-2001 Terms & Conditions: All proposals submitted shall be subject to the terms and conditions set out in this RFP. The State objects to and will not consider any additional terms and conditions submitted with any proposal. Do not attach any additional terms and conditions. By execution and delivery of a proposal, the Vendor agrees that any additional terms and conditions, whether submitted purposely or inadvertently, shall have no force or effect. RFP 30-DMA-284-11 NOTICE TO VENDORS: Vendors are cautioned that requirements of this RFP can only be altered by written addenda and verbal communications from whatever sources are of no effect. All proposals are subject to the provisions of the Request for Proposals for Terms and Conditions, Specifications and General Instructions. The State objects to and will not evaluate or consider any additional terms and conditions submitted with a Vendor’s response. Do not attach any additional terms and conditions. By execution and delivery of this document, the bidder agrees that any additional terms and conditions, whether submitted purposely or inadvertently, shall have no force or effect. This is not an e-procurement solicitation. General information on NC E-Procurement service can be found at http://eprocurement.nc.gov/ Page 2 of 44 RFP 30-DMA-284-11 TABLE OF CONTENTS Section Title Page 1 Purpose & Background 4 2 Instructions to Vendors 6 3 Scope of Work 8 4 Term of Contract 13 5 Invoicing and Compensation 13 6 Vendor Qualifications 14 7 Contents of Proposals 14 8 Evaluation of Proposals 15 9 General Terms & Conditions 17 Attachments A Proposal Execution Page 23 B Business Associate Agreement 24 C Cost Proposal 29 D Federal Identification Number Form 31 E Statement of Financial Condition 32 F Federal Certifications 33 G Conflict of Interest Policy for Private Not-for-Profit Agencies 40 H Executive Order #24 41 I Administrative Rule Governing Award Protests 42 Appendices I DMA-5134 43 II DMA-5315 44 Page 3 of 44 RFP 30-DMA-284-11 SECTION 1 PURPOSE AND BACKGROUND 1.1 Purpose: The purpose of this Request for Proposal (RFP) and any resulting contract award is to solicit proposals from qualified Vendors to conduct day-by-day, ex post facto reviews of the emergency medical care provided to undocumented aliens, and legal aliens who do not qualify for full Medicaid benefits, in order to determine if the subject medical conditions meet the Federal definition of “medical emergency” and therefore qualify for Medicaid reimbursement. 1.2 Background: Medicaid is a health insurance program for certain low-income and needy people, it is paid for with Federal, State, and county dollars. It covers more than 1.7 million people in North Carolina including children, the aged, blind, and/or disabled and people who are eligible to receive federally assisted income maintenance payments. The Division manages the Medicaid program in North Carolina with a budget of over 11 billion dollars, processing over 72 million claims per year. DMA’s Medicaid Eligibility Unity (“MEU”) develops eligibility policies for the North Carolina Medicaid program. Among its many other duties, the MEU ensures that the State’s alien eligibility policies comply with the applicable federal law and regulations and coordinates the State’s alien emergency Medicaid services review process. Under Federal law, undocumented aliens and certain legal aliens who have not resided in the United States of America for more than five (5) years do not qualify for full Medicaid assistance, but do qualify for medical emergency services. Federal policy (P.L. 104.193 Title IV, 42 C.F.R. 435.406 and 435.350, and section 1903(v) (3) of the Social Security Act) limits Medicaid coverage for services considered to be medical emergencies. A medical emergency is defined as a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. Each medical emergency must be reviewed on a day-by-day basis to determine whether the alien qualifies for emergency services and therefore Medicaid eligibility. The alien population has dramatically increased in North Carolina over the past several years as had the need for medical care. The cases to be reviewed have risen exponentially as illustrated below: Calendar Year 2000 1,558 cases reviewed 10 hearings Calendar Year 2001 2,521 cases reviewed 8 hearings Calendar Year 2002 3,250 cases reviewed 15 hearings Calendar Year 2003 3,647 cases reviewed 18 hearings Calendar Year 2004 4,262 cases reviewed 37 hearings Calendar Year 2005 5,449 cases reviewed 24 hearings Calendar Year 2006 5,837 cases reviewed 14 hearings Calendar Year 2007 6,046 cases reviewed 20 hearings Calendar Year 2008 6,892 cases reviewed 17 hearings Calendar Year 2009 7,251 cases reviewed 11 hearings Calendar Year 2010 7,141 cases reviewed 19 hearings In addition to conducting day-by day reviews, the awarded Contractor’s staff must attend appeals that may result from the outcomes of the reviews the Contractor completes. Less than 1% of cases reviewed are appealed. The Contractor’s staff must participate in hearings by attendance either in person or via teleconference. Hearings may be held in any county in NC or in Raleigh. The Contractor’s staff must be able to answer questions regarding their finding and conclusions regarding the issue of medical emergency. 1.3 Definitions, Acronyms and Abbreviations: (a) Center for Medicare and Medicaid Services (CMS): The agency within the Federal Department of Health and Human Services that has primary responsibility for the overall administration and coordination of the Medicare and Medicaid programs. CMS was formerly known as the Health Care Financing Administration. (b) CFR: Code of Federal Regulations Page 4 of 44 RFP 30-DMA-284-11 (c) Contractor: The Vendor selected by DMA to perform the services described in this RFP. The terms Vendor, Contractor, and Offeror are used interchangeably in this document. (d) Day-By-Day Review: Each day for which the applicant has stated an emergency service occurred is reviewed to determine if his or her condition meets the Federal definition of emergency for that day. For example, a person enters the emergency room on January 19 and is admitted to the hospital that day until January 26. The reviewer must review each of the days, January 19, 20, 21, 22, 23, 24, 25 and 26 and determine which of the days, if any meet the definition. (e) DHHS: Department of Health and Human Services (f) DMA: Division of Medical Assistance (g) DSS: County Department of Social Services (h) HIPAA: Health Insurance Portability and Accountability Act of 1996 (i) Legal Alien: Any person not a citizen of the U.S. who is residing in the U.S. under legally recognized and lawfully recorded permanent residence as an immigrant. Also known as "Permanent Resident Alien," "Resident Alien Permit Holder," and "Green Card Holder." (j) Medical Emergency: A medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s heath in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. See Section 1903(v)(3) of the Social Security Act. (k) MEU: Medicaid Eligibility Unit (l) MPR: Medicaid Program Representative, DMA filed staff who work with the counties concerning Medicaid programs. (m) NCAC: North Carolina Administrative Code (n) Proposal: A Vendor’s written response to this request for proposals; a bid. The terms “proposal” and “bid” are used interchangeably in this RFP. (o) State Business Day: Monday through Friday 8:00am – 5:00pm, except State Holidays as defined by the Office of State Personnel at, http://www.osp.state.nc.us/holsched.htm. (p) Reasonable, Necessary or Proper: as used herein shall be interpreted solely by the State of North Carolina. (q) RFP: Request for Proposal (r) SOW: Statement of Work (s) The State: Is the State of North Carolina, and its Agencies. (t) Undocumented Alien: A foreign national who (a) entered the U.S. without inspection or with fraudulent documentation or (b) who, after entering legally as a non-immigrant, violated status and remained in the U.S. without authorization. He is in violation of U.S. immigration law. (u) Vendor: A company, firm, corporation, partnership, individual, etc., submitting a response to a solicitation. 1.4 Mandatory Terminology: This request for Proposal serves two function: (a) Advise potential Vendors of the parameters of the services being sought by the State; and Page 5 of 44 RFP 30-DMA-284-11 (b) Provide (together with other specified documents) the terms of the contract resulting from this procurement. As such, all terms in the Request for Proposal shall be enforceable as contract terms in accordance with the General Terms and Conditions. The use of phrases such as “shall,” “must,” and “requirements” are intended to create enforceable contract conditions. In determining whether proposals should be evaluated or rejected, the State will take into consideration the degree to which Vendors have proposed or failed to propose solutions that will satisfy the State’s needs as described in the Request for Proposal. Except as specifically stated in the RFP, the State may exercise its discretion in determining whether failure to meet one or more requirements shall constitute a basis for rejecting a proposal in its entirety. SECTION 2 INSTRUCTIONS TO VENDORS 2.1 Acceptance of RFP Terms & Conditions: All proposals are subject to the terms and conditions outlined herein. All responses shall be controlled by such terms and conditions and the submission of other terms and conditions, price lists, catalogs, or other documents as part of an Vendor's response shall be waived and have no effect either on this Request for Proposals or on any contract that may be awarded through this solicitation. By submitting an executed proposal, the Offeror specifically agrees to the conditions set forth in this paragraph. 2.2 Certifications: By executing and submitting a proposal, the signer certifies that the proposal is submitted competitively and without collusion (G.S. § 143-54); that none of the Vendor’s officers, directors, or owners (if the Vendor is an unincorporated business entity) have been convicted of any violation of Chapter 78A of the North Carolina General Statutes, the Securities Act of 1933, or the Securities Exchange Act of 1934 (G.S. § 143-59.2); and that the Vendor is not an ineligible Vendor as set forth in G.S. § 143-59.1. False certification is a Class I felony. 2.3 Oral Explanations: The State shall not be bound by oral explanations or instructions given at any time during the competitive process or after award. 2.4 Incorporation by Reference: Materials that are incorporated in a proposal by reference will be considered and evaluated by the State only if copies of the materials are attached to and submitted with the proposal. 2.5 Elaborate Proposals Not Desired: Elaborate proposals in the form of brochures or other presentations beyond that necessary to present a complete and effective proposal are not desired. The State prefers that: (a) All proposals and copies of proposals are printed with text on both sides of each page; (b) All proposals and copies of proposals are printed on recycled paper with a minimum post-consumer content of 30%. (Please confirm this fact within the text of your proposal); (c) All proposals and copies of proposals are produced without the use of non-recyclable or non re-usable materials such as plastic report covers, plastic dividers, vinyl sleeves, and GBC binding. (The use of three- ringed binders, glued materials, paper clips, and staples is acceptable); and (d) All proposals are submitted in a format which allows for easy removal and recycling of paper materials. 2.6 Proposal Costs: Offerors shall be responsible for all costs incurred by them in preparing and submitting their proposals. The State of North Carolina will not reimburse any Offeror for the cost of preparing and submitting a proposal. 2.7 Time For Acceptance: Each proposal must state that it is a firm offer that may be accepted by the State at any time within ninety (90) days following the deadline for submitting the proposal. 2.8 Confidentiality of Proposals: By executing and submitting a proposal, the agrees that it will not disclose the contents of its proposal to any person or entity other than the using or issuing agency, government or private, until after contract award. Only those communications with the using agency or issuing agency authorized by this RFP are permitted. All Offerors are advised that they are not to have any communications with the using or issuing agency during the evaluation of the proposal (i.e. after the public opening of the proposals and before the award of the contract), unless the State’s purchaser contacts the Offeror(s) for purposes of seeking clarification. An Page 6 of 44 RFP 30-DMA-284-11 Offeror shall not: transmit to the issuing and/or using agency any information commenting on the ability or qualifications of other Offerors to perform the advertised contract and/or the other Offerors’ proposals and/or prices at any time during the procurement process; or engage in any other communication or conduct attempting to influence the evaluation and/or award of the contract that is the subject of this RFP. Offerors not in compliance with this provision may be disqualified, at the option of the State, from contract award. Only discussions authorized by the issuing agency are exempt from this provision. 2.9 Ownership of Submitted Materials: All materials submitted in response to this RFP, including all proposals, reports, charts, displays, schedules, exhibits, samples, and correspondence, shall become the property of the State when received by the State. 2.10 Offeror’s Representative: Each Offeror shall submit with its proposal the name, address, and telephone number of one or more persons authorized to bind the Offeror and to answer questions, or provide clarification, regarding the Offeror’s proposal. 2.11 Historically Underutilized Businesses (“HUBs”): Pursuant to G.S. § 143-48 and Executive Order Number 13, the North Carolina Department of Health and Human Services invites and encourages participation in this procurement by businesses owned by minorities, women, the disabled, disabled business enterprises, and non- profit work centers for the blind and severely disabled. To learn more about the State’s HUB program and to apply for HUB designation, visit the following web site: http://www.doa.state.nc.us/hub/ 2.12 Tabulations: The State has implemented an Interactive Purchasing System (IPS) to enable the public to retrieve proposal tabulations electronically from the State’s internet web site at: http://www.ips.state.nc.us/ips/pubmain.asp. Click on the IPS BIDS icon, click on Search for Bid, enter the RFP number, and then search. Tabulations will normally be available at this web site no later than one working day after opening. Lengthy tabulations may not be posted on the internet. 2.13 Vendor Link NC: Vendor Link NC allows vendors to register electronically with the State to receive free electronic notifications of current State procurement opportunities. Free online registration and other purchasing information are available on the State’s internet web site at: http://www.ips.state.nc.us/ips/vendor/vndpubmain.asp. 2.14 Preference May Be Given To North Carolina Products And Citizens: G.S. § 143-59 and 01 NCAC 05B .1522 establish the circumstances and ways in which preference may be given to North Carolina products and citizens. 2.15 Interpretation of Certain Phrases: This Request for Proposal serves two functions: (1) to advise potential Vendors of the parameters of the solution are being sought by the State and two (2) to provide (together with other specified documents) the terms of the contract resulting from this procurement. As such, all terms in the Request for Proposal shall be enforceable as contract terms in accordance with the General Terms and Conditions. The use of phrases such as “shall,” “must,” and “requirements” are intended to create enforceable contract conditions. In determining whether proposals should be evaluated or rejected, the State will take into consideration the degree to which Vendors have proposed or failed to propose solutions that will satisfy the State’s needs as described in the Request for Proposal. Except as specifically stated in the Request for Proposal, no one requirement shall automatically disqualify a Vendor from consideration. However, failure to comply with any single requirement may result in the State exercising its discretion to reject a proposal in its entirety. 2.16 Protest Procedures Award protests are governed by 01 NCAC 05B .1519, an administrative rule promulgated by the North Carolina Department of Administration, Division of Purchase and Contract. A copy of this rule is attached to this RFP as Attachment J. This and other purchasing rules promulgated by the Division of Purchase and Contract can be viewed on-line at: http://reports.oah.state.nc.us/ncac.asp?folderName=\Title%2001%20- %20Administration\Chapter%2005%20-%20Purchase%20and%20Contract Rule 01 NCAC 05B .1519 specifies that some award protests must be submitted to the Secretary of the Department of Administration (or the secretary’s designee) and that some award protests must be submitted to Page 7 of 44 RFP 30-DMA-284-11 the State Purchasing Officer (“SPO”). The contract awarded pursuant to this RFP will be awarded by the Department of Administration, SPO. The SPO’s mailing address is: NC Department of Administration, Division of Purchase and Contract, 1305 Mail Service Center, Raleigh, NC 27699-1305. SECTION 3 SCOPE OF WORK This section describes the work that will be conducted by the firm, hereinafter referred to as the “Offeror”, “Vendor” or “Contractor,” that is awarded the contract for Alien Emergency Medicaid Services Reviews and DMA, hereinafter referred to as the “Division” in the performance of the contract. After contract signing, the Contractor shall meet with the Division to discuss the proposed work plan. 3.1 The Review Process (a) Undocumented aliens and aliens who have not resided more than five (5) years in the United States of America may apply for emergency Medicaid services at the County Department of Social Services. The only services that County Department of Social Services has the authority to approve are regular labor and delivery services. However, the Contractor shall review those labor and delivery cases that have extenuating circumstances such as longer hospital stays or miscarriages and other emergency applications. (b) The County Department of Social Services employee obtains all medical records for the day(s) of service for which the alien had medical services. The employee sends the medical records directly to the Contractor with a cover document, Form DMA-5135 (Appendix II of this RFP), (Date(s) of Emergency Services Requested for an Alien), indicating the applicant’s demographics, dates of service for which the review is being requested, and space for the Physician Reviewer to approve or deny the days requested. The medical records shall be securely submitted using one of the following methods: (1) Packages of hardcopy records shall: (A) Securely closed (so the package will not be opened accidentally during transit) (B) Marked “Confidential” (C) Addressed to a specific person at the Contractor’s organization (D) Return addressed to the County Department of Social Services employee who sent the package (2) Emails shall be encrypted via an encryption method such as ZixMail, WinZip, etc. (3) CD or DVD containing the files shall be encrypted via an encryption method such as WinZip. (c) The amount of information submitted for each case will vary. The size of hard copy records received for one case can range from one inch thick packages to multiple boxes. (d) Upon receipt, the Contractor’s staff reviews the request as detailed in Section 3.2. The Contractor will receive 500-750 requests per month. When a determination has been made, the Contractor notifies the County Department of Social Services directly via secure (see 3.1b, (2)) electronic transmission and returns Form DMA-5135 to the County Department of Social Services. All county departments of social services have access to the internet and email accounts. The Contractor will also provide the Division with copies of the dispositions sent to County Department of Social Services. 3.2 Contractor’s General Responsibilities (a) Medicaid Program Representatives from DMA will perform any training as needed to County Department of Social Services after being assigned by Field Staff Supervisor. (b) The Contractor shall conduct a day-by-day medical record review on each record review request to determine if the medical condition on any one day meets the federal definition of medical emergency. A report of the determination shall be sent electronically to the County Department of Social Services within seven (7) State Business Days of its initial receipt by the Contractor. If the Contractor fails to return a Page 8 of 44 RFP 30-DMA-284-11 determination within the seven (7) State Business Days (by close of business), the Division shall reimburse the Contractor for only fifty percent (50%) of cost for review, as stated in Section 5.1 (c). (c) The Contractor shall create and maintain a log/trackable database of all record review requests coming into and out of their office. This log/trackable database shall be transmitted to the Division’s Contract Administrator at the end of each month as a cumulative summary report in an electronic format. Upon receipt of the Form DMA-5135 and accompanying medical records, an initial inspection will be performed by the support staff. If the form does not include required information (ex: name, date of birth, Medicaid ID number, etc.) or the demographic information on the form does not match the information in the medical records, the entire package will be returned to the County Department of Social Services with Form DMA-5134 (Appendix I of this RFP) which notes the requested information. (d) The Contractor’s Nurse Reviewer shall review each record in its entirety to determine whether emergency medical services were provided on any of the days of service. The Contractor’s Nurse Reviewer shall make this determination by applying the federal definition contained in CMS’s Manual, 3211.11 (Manual can be found at http://www.cms.gov/manuals/pbm/itemdetail.asp?itemid=CMS021927. Click on “Chapter 3-Eligibility” link. When WinZip window opens, open file name “sm 03 3 3201 to 3256.doc”. See relevant section 3211.11 on pages 4-5. (e) If during the course of the review it is determined that portions of the medical records are missing or that additional medical records are required to complete the review, the Contractor’s Nurse Reviewer shall submit Form DMA-5134 to the County Department of Social Services directly and request the missing or needed records through a HIPAA compliant secure electronic transmission. There is no specific time frame that the County Department of Social Services is mandated to provide the requested information. If the requested information is not received within 12 days, an additional request can be sent to the County Department of Social Services. The Contractor’s seven (7) day review period shall be tolled from the date the Contractor notifies the County Department of Social Services that additional records are needed until the date the additional records are received by the Contractor. (f) The Contractor’s Nurse Reviewer shall complete a recommendation sheet for each record reviewed, documenting the review finding and clearly indicating for each service date if the criteria for emergency care were met. If the Nurse Reviewer finds that the client received emergency care for all requested service dates, the Nurse shall approve the application. This approval will be considered the final determination. The Nurse Reviewer shall note the final determination at the bottom portion of the cover document, Form DMA-5135, and sign the document. (g) Records in which the Nurse Reviewer cannot approve all service days as emergency care shall be forwarded to the Contractor’s Physician Reviewer. The Physician Reviewer shall review the nurse’s findings and the medical record and make a final determination. The Physician Reviewer shall note the final determination at the bottom portion of the cover document, Form DMA-5135, and shall sign the document. If additional information is needed during the review, the reviewer shall send Form DMA-5134 to the County Department of Social Services requesting the necessary information. The Contractor’s seven (7) day review period shall be tolled from the date the Contractor notifies the County Department of Social Services that additional records are needed until the date the additional records are received by the Contractor. (h) The Contractor shall communicate its final determinations to the County Department of Social Services each business day via an attachment to a password protected HIPAA compliant, secure electronic transmission and also provide an electronic copy for the Division. (i) For each record reviewed, the hardcopy Form DMA-5135 with the signed final determination shall be forwarded via courier to the County Department of Social Services within seven (7) working days of receiving the complete record. (j) The Contractor shall retain all medical records, review determinations, worksheets, justifications, faxes, and correspondence for the time specified in the Record Retention provision of the General Terms and Conditions, Section 9.25. The Contractor shall also retain records from the previous contract *+for a period of three years following completion of the case review or until all audits are resolved. Page 9 of 44 RFP 30-DMA-284-11 (k) Contractor’s staff shall appear, in person or via teleconferencing, for county and state appeals resulting from the review determinations. A caseworker from the County Department of Social Services will contact the Contractor if participation in an appeal/hearing is needed. A county hearing would be scheduled within five (5) days of the client’s request. Notification of a state hearing could take longer. For the appeal/hearing, the Contractor shall have available all documents, including recommendation sheets pertaining to the review in question. The Contractor’s staff shall answer questions about their finding(s) regarding medical emergency. The Contractor’s staff needs to be available a minimum of three (3) days a week (chosen by the Contractor) for hearings. 3.3 Required Reports All data transfers shall be secure and compliant with the provisions of 45 CFR 164 in order to protect all personal health information from unauthorized disclosure. See Attachment B, Business Associate Agreement. All reports shall be transmitted to the Division’s Contract Administrator monthly as specified below in an electronic format. (a) Monthly Compilation Report th (1) The Contractor shall transmit electronically a compilation report, on the tenth (10 ) of each month listing all activities performed by the Contractor during the previous month. This report shall indicate the number of cases reviewed and the time spent preparing and participating in hearings either via teleconference or in person. This monthly compilation report shall be sent to the Division at the time that the monthly invoice is sent and shall serve as the detailed description of the time billed on the invoice. (2) The monthly compilation report shall contain, for each case reviewed: (A) Applicant’s name (B) Applicant’s Medicaid Identification Number (C) Aid Program/Category (D) Sex (E) Date of Birth (F) Date received from the County Department of Social Services (G) Date the determination was returned to the County Department of Social Services (H) Date(s) of service requested (I) Date(s) of service approved (Contractor shall write “NONE” if all dates are denied) (J) Case determination, denied or approved, and the medical reasons for the determination. This determination will be based on the principal diagnosis noted in the medical records. (3) Additionally, the Contractor shall total each diagnosis/clinical reason for approval or disapproval on cases reviewed each month. (4) The monthly compilation report shall contain, for each hearing at which the Contractor represented the Division, via teleconference or in person: (A) Case name (B) Medicaid Identification Number (C) Note if the hearing was held (D) Date hearing was held (E) Time spent preparing for or participating in hearings/appeals (b) Additional Reports (1) Additional reports may be requested by the Division from the Contractor. (2) When requested by the Division, the Contractor shall make available all records, papers, vouchers, correspondence and other documentation associated with this Contract. The Page 10 of 44 RFP 30-DMA-284-11 Contractor shall grant access to these documents to the Division personnel, Federal officials, or other State officials such as the North Carolina Office of the State Auditor upon request. 3.4 Confidentiality (a) The Contractor and its subcontractors, if any, are required by State and Federal law to maintain the confidentiality of all medical records. (b) The Contractor is entitled to view all provider medical records to which the Division itself is entitled under its Contract to reimburse providers for services. (c) Such records received by the Contractor shall be shared only with the Division or with other parties approved in writing by the applicant, the applicant’s guardian and the Division. (d) All individuals involved in the review process shall treat all medical records and clinical information as confidential. 3.6 Staff Upon execution of the contract, resumes for all of the Contractor’s current professional staff shall be forwarded to the Division (via email or hardcopy) for review and approval. Resumes for any professional staff shall be forwarded to the Division (via email or hardcopy) for review and approval prior to the hiring date the Contractor proposes to hire at any time during the term of this Contract for the sole purpose of carrying out duties outlined in the Scope of Work, The Contractor shall not substitute key personnel assigned to the Contract without prior written approval by the Division. The Division reserves the right to review and approve or disapprove each proposed professional staff member. (a) Nurse Reviewer The Contractor’s Nurse Reviewers shall have the following minimum qualifications. The contractor shall include in their proposal the exact number of Nurse Reviewers who meet or exceed the minimum requirements below. (1) Graduation from a state accredited school of professional nursing, (2) Three (3) years experience in more than one patient care setting (ex: hospital, doctor’s office, clinic) (3) A license from the North Carolina Board of Nursing to practice nursing in the state of North Carolina, and (4) Certification in a nursing specialty (b) Physician Reviewer The Contractor’s Physician Reviewers shall meet the following minimum qualifications. The contractor shall include in their proposal the exact number of physician reviewers who meet or exceed the minimum requirements below: (1) The physician shall be an Internist or General Practitioner licensed to practice medicine in the state of North Carolina, (2) The physician shall be a graduate of an accredited school of medicine who has completed his or her residency or specialty training, and (3) The physician shall have at least one (1) year of experience in the practice of medicine. (c) Other The Contractor shall retain other support staff as required for: Page 11 of 44 RFP 30-DMA-284-11 (1) Maintaining the medical records (2) Submitting reports/invoices (3) Maintaining the log/database of cases reviewed and (4) Any other administrative functions as needed to carry out the terms and conditions of this Contract. 3.7 Meetings At the Division’s request, the Contractor shall meet no more than once a month with the Division at the Division’s office in Raleigh, North Carolina or another mutually agreeable site to discuss issues encountered by the Contractor, to review reports submitted and to discuss work flow. 3.8 Contract Administrator (a) Upon execution of the contract the Contractor shall designate a single Contract Administrator to be the primary contact with the Division for all issues regarding this Contract. (b) The Contractor’s Contract Administrator must be available by phone, facsimile, or e-mail Monday – Friday, 8:00 a.m. to 5:00 p.m. All responses must be received within one (1) business day. 3.9 Data Ownership (a) The Contractor agrees that all data and records provided by the Division to the Contractor is owned by the Division and shall be used only for the purposes in this SOW. (b) All data created in any form pursuant to the contract awarded pursuant to this RFP shall become the property of the Division and shall be accessible by the Division at any time. (c) All data associated with this contract shall be transferred to the Division and accepted by the Division prior to final payment to Contractor at the end of the contract. (d) Under no circumstances shall the Contractor share data with any other entity without prior written authorization by the Division. 3.10 Contract Transition (a) Three (3) months prior to the expiration of this Contract, the Contractor shall provide to the Division a written transition plan designed to insure a smooth transition for the new vendor. The Contractor shall take all reasonable action to provide a minimally disruptive changeover. The Contractor must obtain the written approval of the Division’s Contract Administrator before it implements the transition plan. (b) Upon the expiration of this Reviews of Emergency Medicaid Services Provided to Aliens contract, the current Contractor shall deliver all accumulated records to the Division. (c) The new Contractor shall obtain case records that are essential in performing the task outlined in the SOW (hardcopy and electronic files from approximately 21,000 cases) from the Division that were accumulated from the previous contract and store them for the duration of the new contract. The Contractor shall retain all records for a period of three years following completion of the case review or until all audits are resolved. Written approval must be received from the Division Director before records and files can be purged. 3.11 Travel Any travel expenses accrued by the Contractor for training or hearings around the state will be paid by the State on a per diem basis. Page 12 of 44 RFP 30-DMA-284-11 3.12 Division Responsibilities (a) The Division shall pay the Contractor as specified in Section 5.1. (b) The Division shall provide the Contractor records/data/files it needs to perform the tasks in the SOW. The Contractor will not be responsible for any costs associated with obtaining the records. The State will retain ownership of all records/data/files that the Contractor is provided. (c) The Division shall maintain an electronic database of all disposition reasons returned to the County Department of Social Services by the Contractor after a determination has been made. (d) Division staff shall be available for consultation with the Contractor during State Business Days and hours at the Division’s offices in Raleigh, NC via phone, fax, e-mail or in person for the purpose of discussing matters pertinent to the performance of the Contract. SECTION 4 TERM OF CONTRACT; OPTIONS TO EXTEND; PRICE INCREASES 4.1 The term of the Contract shall be one (1) year with the option to extend for two (2) additional years in increments of one (1) year each. SECTION 5 INVOICING & COMPENSATION 5.1 Invoicing (a) By no later than the tenth (10th) of each month, the Contractor shall submit an invoice to the Division’s Contract Administrator that specifies the time spent on behalf of the Division during the preceding month. The monthly invoice should detail the following: (1) The number of case reviews completed (2) Time spent preparing for and participating in hearings (charged in 15 minute increments) (b) The Division will process invoices net thirty (30) days, upon receipt and acceptance of the Contractor’s itemized monthly invoices. (c) If the Contractor fails to return a report for each determination within the seven (7) State Business Days (close of business), the Division will only reimburse the Contractor fifty percent (50%) of the Contractor’s total time charged to review the record. (d) The Contractor shall be paid for determinations regardless of outcome. (e) Invoices shall be submitted to one of the following addresses: Delivery by US Mail Service Delivery by Overnight Delivery NC Department of Health & Human Services NC Department of Health & Human Services Division of Medical Assistance Division of Medical Assistance Medicaid Eligibility Unit Medicaid Eligibility Unit Attention: Joy H. Smith Attention: Joy H. Smith 2501 Mail Service Center 801 Ruggles Dr., Hoey Bldg. Raleigh, NC 27699-2501 Raleigh, NC 27603 Page 13 of 44 RFP 30-DMA-284-11 (f) When the contract is executed, the contractor will receive the purchase order number to which all contract related services will be billed. Invoices should bear the correct purchase order number to ensure prompt payment. The Contractor’s failure to include the correct purchase order number may cause delay in payment. (g) Invoices must itemize the work for which payment is sought. SECTION 6 VENDOR QUALIFICATIONS 6.1 Be able to perform work as outlined in Section 3 (Scope of Work) upon the execution of the contract. 6.2 Have at a minimum three (3) years experience conducting reviews for medical services. SECTION 7 CONTENTS OF PROPOSALS 7.1 Technical Proposal: At a minimum, the Vendor’s Technical Proposal must contain the items listed below. These items should be arranged in the Technical Proposal in the order in which they are listed, below. (a) A Transmittal Letter signed, by the individual who signs the Execution Page; (b) An Execution Page (RFP Attachment A) signed by an individual authorized to bind the Vendor. Unsigned proposals shall not be reviewed; (c) Evidence that the Vendor possesses the Qualifications specified in RFP Section 6; (d) Three (3) references (including the name of a contact person and that person’s telephone number and email address); (e) A list of all Medicaid agencies for which the Offeror currently performs similar work; (f) A summary of the Offeror’s experience in conducting reviews of emergency medical services provided to aliens; (g) A description of the Offeror’s organization, including: (1) The names and resumes of Key Contractor Personnel, whether those Key Contractor Personnel are the Offeror’s employees or independent contractors; (2) A list of all similar projects on which the Vendor is presently working, including the name, telephone number, and email address of a client contact person; (3) A list of all similar projects the Vendor has completed within the last three years, including the name, telephone number, and email address of a client contact person; (4) A description of all subcontractors the Offeror intends to use on this Contract, if any; (5) A work plan, including at a minimum: (A) The Offeror’s schedule and methodology for completing the services detailed in RFP Section 4.0; (B) A discussion of potential problems that could interfere with the timely completion of the tasks described in RFP Section 4.0 and proposed solutions to those problems; (C) Resumes and credentials of all proposed staff that will perform reviews and reconsideration hearings; Page 14 of 44 RFP 30-DMA-284-11 (7) The details of any pertinent judgments, criminal convictions, investigations or litigation pending against the Offeror or any of its officers, directors, employees, agents or subcontractors of which the Offeror has knowledge, or a statement that there are none. The Agency reserves the right to reject a proposal solely on the basis of this information; and (8) RFP Attachments A through H. All attachments must be signed by an individual authorized to bind the Offeror. (b) Do not enter any cost information in the Technical Proposal. 7.2 Cost Proposal: (a) The Vendor’s Cost Proposal must be submitted in the tabular format provided in RFP Attachment C (Cost Proposal). The Agency may reject a proposal solely on the ground that the Vendor’s Cost Proposal was not submitted in the prescribed format. (b) Do not enter any technical information in the Cost Proposal. SECTION 8 EVALUATION OF PROPOSALS 8.1 Introduction The State will conduct a comprehensive, fair, and impartial evaluation of the proposals received in response to this request. All proposals will be evaluated using a one-step method. As provided by statute, award will be based on the lowest and best proposal (most advantageous to the State). Cost is important but is not an overriding consideration. The award of a contract to one Vendor does not mean that the other Vendors’ proposals lack merit. The State reserves the right to reject any or all proposals. 8.2 Evaluation Committee An Evaluation Committee will read the proposals, conduct corporate and personal reference checks, score the proposals, and make a written recommendation to the DHHS Office of Procurement and Contract Services. The State may change the size or composition of the committee during the review in response to exigent circumstances. 8.3 Scoring The Evaluation Committee will score the proposals using the scoring system shown in Table 8.4, below. The highest score that can be awarded to any proposal is 1000 points. Table 8.4 – Scoring System Technical Evaluation Factor Highest Possible Score Technical Technical Approach to RFP (Understanding SOW) 450 Proposal 1. Examples of previous contracts in which the Contractor 150 completed at least 500 medical case reviews each month. 2. Example of a monthly compilation report as outlined in Section 60 3.3a. 3. An example of a log/trackable database of case reviews as 60 outlined in Section 3.2c. 4. An example of a nurse review recommendation sheet as 60 outlined in Section 3.2e. 5. Detailed outline of the Contractor’s record retention protocol. 60 6. Confirmation that reviewers will be able to travel to any county in the state of North Carolina to participate in hearings/appeals 60 if teleconferencing is not possible (Section 3.2j). Page 15 of 44 RFP 30-DMA-284-11 Total Score for Technical Approach to RFP (Understanding SOW) Experience/ Qualifications of the Offeror’s Review Staff & 250 Organization References Staff Qualifications and Staffing Plan 110 Vendor Qualifications 110 References 30 Total Score for Experience/ Qualifications of the Offeror’s Review Staff & Organization References Subtotal – Technical Proposal 700 Cost Proposal 300 Total Possible Score 1000 8.5 Evaluation Phases (a) Phase 1: Evaluation of Technical Proposals (1) Phase 1, Part 1: Staff will summarily review each proposal to determine whether the proposal was properly executed and timely submitted. All timely submitted proposals for which signed execution pages have been received as provided above will be forwarded to the Evaluation Committee for review. Proposals that are not forwarded to the Evaluation Committee are ineligible for contract award. Phase 1, Part 2: Each member of the Evaluation Committee will read each technical proposal that has been forwarded to the Committee. The members of the Evaluation Committee will meet together and score each technical proposal, by consensus, on each of the technical evaluation factors shown in Table 8.4, above. (b) Phase 2: Evaluation of Cost Proposals The State will evaluate each Cost Proposal for completeness and reasonableness. The State may reject a proposal if the Cost Proposal is incomplete or if it contains significant inconsistencies or inaccuracies. The State will determine low cost by normalizing the scores as follows: The proposal with the lowest cost will receive a sore of 300. All other competing proposals will be assigned a portion of the maximum score using the formula: the cost of the lowest cost proposal 300 X the cost of the cost proposal being evaluated (c) Phase 3: Determination of Successful Proposal (1) The Vendor whose proposal is determined to be in the best interest of the State will be recommended as the successful Contractor. The Evaluation Committee will forward this Vendor’s name to the DHHS Office of Procurement and Contract Services with documentation to justify the Committee’s recommendation. Page 16 of 44 RFP 30-DMA-284-11 (2) The DHHS Office of Procurement and Contract Services will review the Committee’s recommendation and forward it (with a copy of the Technical and Cost Proposals) to the North Carolina Department of Administration, Division of Purchase and Contract for approval. (3) When the final approval is received, the State will notify the selected Vendor. If the State rejects all proposals, it will notify all Vendors. The State will post the award on the State website at www.ips.state.nc.us. The award will be posted under the applicable RFP number. (4) The Contract between DHHS and the selected Vendor shall be effective as of the date on which the Division’s authorized agent signs the Vendor’s proposal. The selected Vendor shall perform no work for the Division before that date. 8.6 Oral Presentations & Clarifications (a) During its evaluation of the competing proposals, the Evaluation Committee may ask the Vendors to make oral presentations to the Committee regarding the contents of their Technical Proposals. These oral presentations will be scheduled and conducted solely for the purpose of clarifying the information in the proposals. The Vendors may not use these presentations to submit new information that was not submitted in the proposals under review. (b) DHHS may contact a Vendor during the evaluation period to obtain clarification regarding the Vendor’s proposal. Contract award notices are sent only to those actually awarded contracts, and not to every person or firm responding to this solicitation. Contract status and award notices are posted on the Internet at http://www.ips.state.nc.us/ips/pubmain.asp. SECTION 9 GENERAL TERMS & CONDITIONS 9.1 Contract Documents: The Contract that is awarded as a consequence of this RFP shall consist of the following documents: (a) The Addenda to this RFP, if any; (b) This RFP; and (c) The Contractor’s Proposal. In the event of a conflict between or among the terms of the Contract Documents, the term in the Contract Document with the highest precedence shall prevail. The Addenda to the RFP (if any) shall have the highest precedence, the RFP shall have the second highest precedence, and the Successful Vendor’s proposal shall have the third highest precedence. These documents shall constitute the entire agreement between the parties and supersede all other prior oral or written statements or agreements. 9.2 Contract Administrators: The Contract Administrators are the persons to whom all required notices shall be given and to whom all matters relating to the administration or interpretation of this Contract shall be addressed. The Contractor shall designate a single Contract Administrator, who shall be the Contractor’s primary contact with the Division for all issues regarding this Contract. The Contractor shall identify its initial Contract Administrator in its proposal and shall confirm the name, title, address, telephone number, facsimile number, and email address of its Contractor Administrator within 5 business days after the Effective Date of the Contract. The Contractor’s Contract Administrator shall be available by phone, facsimile, or e-mail, upon 24 hours notice. The Division’s contract administrators are named below. Division Contract Administrators For All Day-To-Day Activities For All Other Described In Section 3 Contract Issues Joy H. Smith Sherry Cannady Medicaid Eligibility Unit Contracting Supervisor Division of Medical Assistance Division of Medical Assistance Page 17 of 44 RFP 30-DMA-284-11 2501 Mail Service Center 1985 Umstead Drive, Kirby Building Raleigh, NC 27699-2501 2501 Mail Service Center Raleigh NC 27699-2501 Telephone: 855-4036 Telephone: (919) 855-4154 Facsimile: 715-0801 Facsimile: (919) 715-0896 E-mail: Joy.Smith@dhhs.nc.gov E-mail: email@example.com Either party may change the identity of its Contract Administrator or change the contact information for its Contract Administrator by giving timely written notice of the change to the other party. 9.3 Independent Contractor: The Contractor is and shall be deemed to be an independent contractor in the performance of this contract and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Contractor represents that it has, or shall secure at its own expense, all personnel required in performing the services under this agreement. Such employees shall not be employees of, or have any individual contractual relationship with, the Division. 9.4 Subcontracting: The Contractor shall not subcontract any of the work contemplated under this contract without prior written approval from the Division. Any approved subcontract shall be subject to all conditions of this contract. Only the subcontractors specified in the contract documents are to be considered approved upon award of the contract. The Division shall not be obligated to pay for any work performed by any unapproved subcontractor. The Contractor shall be responsible for the performance of all of its subcontractors. 9.5 Assignment: No assignment of the Contractor's obligations or the Contractor's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, the State may: (a) Forward the Contractor's payment check(s) directly to any person or entity designated by the Contractor; or (b) Include any person or entity designated by Contractor as a joint payee on the Contractor's payment check(s). In no event shall such approval and action obligate the State to anyone other than the Contractor and the Contractor shall remain responsible for fulfillment of all contract obligations. 9.6 Beneficiaries: Except as herein specifically provided otherwise, this contract shall inure to the benefit of and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the enforcement of the terms and conditions of this contract, and all rights of action relating to such enforcement, shall be strictly reserved to the Division and the named Contractor. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any other third person. It is the express intention of the Division and Contractor that any such person or entity, other than the Division or the Contractor, receiving services or benefits under this contract shall be deemed an incidental beneficiary only. 9.7 Indemnification: The Contractor agrees to indemnify and hold harmless the Division, the State of North Carolina, and any of their officers, agents and employees, from any claims of third parties arising out or any act or omission of the Contractor in connection with the performance of this contract. 9.8 Insurance (a) During the term of the contract, the Contractor shall provide, at its sole cost and expense, commercial insurance of such types and with such terms and limits as may be reasonably associated with the contract. At a minimum, the Contractor shall provide and maintain the following coverage and limits: (1) Worker’s Compensation Insurance: The Contractor shall provide and maintain worker’s compensation insurance, as required by the laws of the states in which its employees work, covering all of the Contractor’s employees who are engaged in any work under the contract. Page 18 of 44 RFP 30-DMA-284-11 (2) Employer’s Liability Insurance: The Contractor shall provide employer’s liability insurance, with minimum limits of $500,000.00, covering all of the Contractor’s employees who are engaged in any work under the contract. (3) Commercial General Liability Insurance: The Contractor shall provide commercial general liability insurance on a comprehensive broad form on an occurrence basis with a minimum combined single limit of $1,000,000.00 for each occurrence. (4) Automobile Liability Insurance: The Contractor shall provide automobile liability insurance with a combined single limit of $500,000.00 for bodily injury and property damage; a limit of $500,000.00 for uninsured/under insured motorist coverage; and a limit of $2,000.00 for medical payment coverage. The Contractor shall provide this insurance for all automobiles that are: (A) owned by the Contractor and used in the performance of this contract; (B) hired by the Contractor and used in the performance of this contract; and (C) owned by Contractor’s employees and used in performance of this contract (“non-owned vehicle insurance”). Non-owned vehicle insurance protects employers when employees use their personal vehicles for work purposes. Non-owned vehicle insurance supplements, but does not replace, the car-owner’s liability insurance. The Contractor is not required to provide and maintain automobile liability insurance on any vehicle – owned, hired, or non-owned -- unless the vehicle is used in the performance of this contract. (b) The insurance coverage minimums specified in subparagraph (a) are exclusive of defense costs. (c) The Contractor understands and agrees that the insurance coverage minimums specified in subparagraph (a) are not limits, or caps, on the Contractor’s liability or obligations under this contract. (d) The Contractor may obtain a waiver of any one or more of the requirements in subparagraph (a) by demonstrating that it has insurance that provides protection that is equal to or greater than the coverage and limits specified in subparagraph (a). The Division shall be the sole judge of whether such a waiver should be granted. (e) The Contractor may obtain a waiver of any one or more of the requirements in paragraph (a) by demonstrating that it is self-insured and that its self-insurance provides protection that is equal to or greater than the coverage and limits specified in subparagraph (a). The Division shall be the sole judge of whether such a waiver should be granted. (f) Providing and maintaining the types and amounts of insurance or self-insurance specified in this paragraph is a material obligation of the Contractor and is of the essence of this contract. (g) The Contractor shall only obtain insurance from companies that are authorized to provide such coverage and that are authorized by the Commissioner of Insurance to do business in the State of North Carolina. All such insurance shall meet all laws of the State of North Carolina. (h) The Contractor shall comply at all times with all lawful terms and conditions of its insurance policies and all lawful requirements of its insurer. (i) The Contractor shall require its subcontractors to comply with the requirements of this paragraph. (j) The Contractor shall demonstrate its compliance with the requirements of this paragraph by submitting certificates of insurance to the Division before the Contractor begins work under this contract. 9.9 Liability Claims Against The Contractor: Neither the State of North Carolina, nor its employees shall be responsible for any liability claims against the Contractor. Page 19 of 44 RFP 30-DMA-284-11 9.10 Termination Without Cause: The Division may terminate this contract without cause by giving 30 days written notice to the Contractor. In that event, all finished or unfinished deliverable items prepared by the Contractor under this contract shall, at the option of the Division, become its property and the Contractor shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any payment or compensation previously made. 9.11 Termination for Cause: If, through any cause, the Contractor shall fail to fulfill its obligations under this contract in a timely and proper manner, the Division shall have the right to terminate this contract by giving written notice to the Contractor and specifying the effective date thereof. In that event, all finished or unfinished deliverable items prepared by the Contractor under this contract shall, at the option of the Division, become its property and the Contractor shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any payment or compensation previously made. Notwithstanding the foregoing provision, the Contractor shall not be relieved of liability to the Division for damages sustained by the Division by virtue of the Contractor’s breach of this agreement, and the Division may withhold any payment due the Contractor for the purpose of setoff until such time as the exact amount of damages due the Division from such breach can be determined. In case of default by the Contractor, without limiting any other remedies for breach available to it, the Division may procure the contract services from other sources and hold the Contractor responsible for any excess cost occasioned thereby. The filing of a petition for bankruptcy by the Contractor shall be an act of default under this contract. 9.12 Waiver of Default: Waiver by the Division of any default or breach in compliance with the terms of this contract by the Provider shall not be deemed a waiver of any subsequent default or breach and shall not be construed to be modification of the terms of this contract unless stated to be such in writing, signed by an authorized representative of the Department and the Contractor and attached to the contract. 9.13 Proprietary Information: Trade secrets or similar proprietary data which the Vendor does not wish disclosed to other than personnel involved in the evaluation or contract administration will be kept confidential to the extent permitted by NCAC T01:05B.1501 and G.S. 132-1.2 if identified as follows: Each page shall be identified in boldface at the top and bottom as "CONFIDENTIAL". Any section of the proposal which is to remain confidential shall also be so marked in boldface on the title page of that section. Cost information may not be deemed confidential. In spite of what is labeled as confidential, the determination as to whether or not it is shall be determined by North Carolina law. 9.14 Availability of Funds: The parties to this contract agree and understand that the payment of the sums specified in this contract is dependent and contingent upon and subject to the appropriation, allocation, and availability of funds for this purpose to the Division. 9.15 Force Majeure: Neither party shall be deemed to be in default of its obligations hereunder if and so long as it is prevented from performing such obligations by any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event or act of God. 9.16 Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained herein shall survive the contract expiration or termination date unless specifically provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation. 9.17 Compliance with Laws: The Contractor shall comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of federal, state, and local agencies having jurisdiction and/or authority. 9.18 Equal Employment Opportunity: The Contractor shall comply with all federal and State laws relating to equal employment opportunity. 9.19 Health Insurance Portability and Accountability Act (HIPAA): The Contractor agrees that, if the Division determines that some or all of the activities within the scope of this contract are subject to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-91, as amended (“HIPAA”), or its implementing regulations, it will comply with the HIPAA requirements and will execute such agreements and practices as the Division may require to ensure compliance. 9.20 Confidentiality: Any information, data, instruments, documents, studies or reports given to or prepared or assembled by the Contractor under this agreement shall be kept as confidential and not divulged or made Page 20 of 44 RFP 30-DMA-284-11 available to any individual or organization without the prior written approval of the Division. The Contractor acknowledges that in receiving, storing, processing or otherwise dealing with any confidential information it will safeguard and not further disclose the information except as otherwise provided in this contract. 9.21 Data Ownership: The Contractor understands and agrees that all data provided by the Division to the Contractor is owned by the Division and shall be used by the Contractor solely for the puposes described in this contract. All data created in any form as part of this contract shall be the property of the Division and shall be available to the Division at all times. At the end of the contract, all data associated with this contract shall be transferred to and accepted by the Division prior to final payment to the Contractor. Under no circustances shall the Contractor share the data with any other entity without the Division Contract Administrator’s prior written authorization. 9.22 Copyrights and Ownership of Deliverables: All deliverable items produced pursuant to this contract are the exclusive property of the Division. The Contractor shall not assert a claim of copyright or other property interest in such deliverables. If a Vendor determines that every statement and item on any given page of its proposal constitutes a confidential trade secret, as that term is defined in G.S. 66-152(3), the Vendor may designate the entire page as confidential by marking the top and bottom of the page with the word “CONFIDENTIAL” in upper- case, bold-face type. If a Vendor determines that any given page of its proposal contains a mixture of confidential trade secrets and non-confidential information, the Vendor should highlight the confidential trade secrets and indicate in the margin that the highlighted text constitutes confidential trade secret. By so marking any page, the Vendor warrants that it has formed a good faith opinion, having received such necessary or proper review by counsel and other knowledgeable advisors, that the portions marked confidential meet the requirements of the Rules and Statues set forth above. However, under no circumstances shall price information be designated as confidential. 9.23 Federal Intellectual Property Bankruptcy Protection Act: The Parties agree that the Division shall be entitled to all rights and benefits of the Federal Intellectual Property Bankruptcy Protection Act, Public Law 100-506, codified at 11 U.S.C. 365 (n), and any amendments thereto. 9.24 Access to Persons and Records: The State Auditor and the using agency's internal auditors shall have access to persons and records as a result of all contracts or grants entered into by State agencies or political subdivisions in accordance with General Statute 147-64.7 and Session Law 2010-194, Section 21 (i.e., the State Auditors and internal auditors may audit the records of the contractor during the term of the contract to verify accounts and data affecting fees or performance). The Contractor shall give the Division, the N.C. Department of Health and Human Services, the North Carolina State Auditor, the U.S. Department of Health and Human Services, and their employees and agents, access to all persons, books, records, and accounts necessary to enable those agencies to audit the Contractor’s performance under this Contract. 9.25 Record Retention: The Department of Health and Human Services' basic records retention policy requires all records to be retained for a minimum of three years following completion or termination of the contract. If the contract is subject to Federal policy and regulations, record retention will normally be longer than three years since records must be retained for a period of three years following submission of the final Federal Financial Status Report, if applicable, or three years following the submission of a revised final Federal Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving this contract has been started before expiration of the three year retention period described above, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular three year period described above, whichever is later. Therefore, records shall not be destroyed, purged or disposed of without the express written consent of the Division. 9.26 Date and Time Warranty: The Contractor warrants that the product(s) and service(s) furnished pursuant to this contract (“product” includes, without limitation, any piece of equipment, hardware, firmware, middleware, custom or commercial software, or internal components, subroutines, and interfaces therein) that perform any date and/or time data recognition function, calculation, or sequencing will support a four digit year format and will provide accurate date/time data and leap year calculations. This warranty shall survive the termination or expiration of this contract. 9.27 Certification Regarding Collection of Taxes: G.S. § 143-59.1 bars the Secretary of Administration from entering into contracts with vendors that meet one of the conditions of G.S. § 105-164.8(b) and yet refuse to collect use taxes on sales of tangible personal property to purchasers in North Carolina. The conditions include: Page 21 of 44 RFP 30-DMA-284-11 (a) maintenance of a retail establishment or office; (b) presence of representatives in the State that solicit sales or transact business on behalf of the Vendor; and (c) systematic exploitation of the market by media-assisted, media-facilitated, or media-solicited means. The Contractor certifies that it and all of its affiliates (if any) collect all required taxes. 9.28 Choice of Law: The validity of this contract and any of its terms or provisions, as well as the rights and duties of the parties to this contract, are governed by the laws of North Carolina. The Contractor, by signing this contract, agrees and submits, solely for matters concerning this Contract, to the exclusive jurisdiction of the courts of North Carolina and agrees, solely for such purpose, that the exclusive venue for any legal proceedings shall be Wake County, North Carolina. The place of this contract and all transactions and agreements relating to it, and their situs and forum, shall be Wake County, North Carolina, where all matters, whether sounding in contract or tort, relating to the validity, construction, interpretation, and enforcement shall be determined. 9.29 Amendment: This contract may not be amended orally or by performance. Any amendment must be made in written form and executed by duly authorized representatives of the Division and the Contractor. The Purchase and Contract Divisions of the NC Department of Administration and the NC Department of Health and Human Services shall give prior approval to any amendment to a contract awarded through those offices. 9.30 Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this contract violates any applicable law, each such provision or requirement shall continue to be enforced to the extent it is not in violation of law or is not otherwise unenforceable and all other provisions and requirements of this contract shall remain in full force and effect. 9.31 Headings: The Section and Paragraph headings in these General Terms and Conditions are not material parts of the agreement and should not be used to construe the meaning thereof. 9.32 Time of the Essence: Time is of the essence in the performance of this contract. 9.33 Key Personnel: The Contractor shall not replace any of the key personnel assigned to the performance of this contract without the prior written approval of the Division. The term “key personnel” includes any and all persons identified as such in the contract documents and any other persons subsequently identified as key personnel by the written agreement of the parties. 9.34 Care of Property: The Contractor agrees that it shall be responsible for the proper custody and care of any property furnished to it for use in connection with the performance of this contract and will reimburse the Division for loss of, or damage to, such property. At the termination of this contract, the Contractor shall contact the Division for instructions as to the disposition of such property and shall comply with these instructions. 9.35 Travel Expenses: The Contractor shall be responsible for all travel expenses arising out of the Contractor’s performance of its duties under this Contract; the Division shall not reimburse the Contractor for any international travel expenses. 9.36 Sales/Use Tax Refunds: If eligible, the Contractor and all subcontractors shall: (a) ask the North Carolina Department of Revenue for a refund of all sales and use taxes paid by them in the performance of this contract, pursuant to G.S. § 105-164.14; and (b) exclude all refundable sales and use taxes from all reportable expenditures before the expenses are entered in their reimbursement reports. 9.37 Advertising: The Contractor shall not use the award of this contract as a part of any news release or commercial advertising. Page 22 of 44 RFP 30-DMA-284-11 ATTACHMENT A Proposal Execution Page By submitting this proposal, the Vendor certifies the following: 1. This proposal is signed by an authorized representative of the firm; 2. All labor costs, direct and indirect, have been determined and included in the proposed cost; 3. The Vendor has read and understands the terms and conditions set forth in this RFP and agrees to them without exception; and 4. The Vendor is registered in NC E-Procurement @ Your Service or agrees to register within two (2) days after notification of contract award. The E-Procurement Service fee does NOT apply to this RFP. Name of Vendor: ______________________________________________________________________________ Vendor’s Street Address:_______________________________________________________________________ City, State, Zip Code: __________________________________________________________________________ Vendor’s Telephone No: ________________________________ Vendor’s FAX: __________________________ Vendor’s E-Mail Address: _______________________________________________________________________ Principal Place of Business if different from above:__________________________________________________ ______________________________________________________________________________________________ [The “Principal Place of Business” is the principal place from which the trade or business of the Vendor is directed or managed.] Will any of the work under this contract be performed outside the United States? Yes No If “yes” is checked, explain answer in technical proposal. ________________________________________________________________________________/______________ Signature Date ____________________________________________________________________/__________________________ Printed Name Title THIS PAGE MUST BE SIGNED AND DATED AND SUBMITTED WITH YOUR PROPOSAL Unsigned proposals will not be considered ACCEPTANCE OF PROPOSAL BY DIVISION OF ___________________________ _________________________________________________________________________________________________ Signature Date _________________________________________________________________________________________________ Printed Name Title Page 23 of 44 RFP 30-DMA-284-11 ATTACHMENT B North Carolina Department Of Health And Human Services Division of Medical Assistance Business Associate Agreement Request for Proposal (“RFP”) No. 30-DMA-284-11 This Agreement is made by and between the Division of Medical Assistance (“DMA” or “Covered Entity”) and the Offeror named at the end of this Agreement (“Offeror” or “Business Associate”). DMA and Offeror are collectively referred to hereinafter as the “Parties.” This Agreement shall become effective only if the DMA awards a contract to Offeror pursuant to the above-referenced RFP. This Agreement shall become effective on, and terminate on, the same dates as said contract. 1. BACKGROUND a. Offeror has submitted a proposal in response to the above-referenced Request for Proposals. b. DMA is an organizational unit of the North Carolina Department of Health and Human Services that has been designated in whole or in part by the Department as a health care component (“Covered Component”) for purposes of the HIPAA Privacy and Security Rules. c. If DMA awards a contract to Offeror, the relationship between DMA and Offeror will be such that the Parties believe Offeror will be DMA’s “business associate” of within the meaning of the HIPAA Privacy and Security Rules. d. The Parties enter into this Business Associate Agreement with the intention of complying with the HIPAA Privacy and Security Rules provision that a covered entity may disclose electronic protected health information or other protected health information to a business associate, and may allow a business associate to create or receive electronic protected heath information or other protected health information on its behalf, if the covered entity obtains satisfactory assurances that the business associate will appropriately safeguard the information. 2. DEFINITIONS Unless some other meaning is clearly indicated by the context, the following terms shall have the following meaning in this Agreement: a. “Electronic Protected Health Information” shall have the same meaning as the term “electronic protected health information” in 45 CFR 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity. b. “HIPAA” means the Administrative Simplification Provisions, Sections 261 through 264, of the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191. c. “Individual” shall have the same meaning as the term “individual” in 45 CFR160.103 and Page 24 of 44 RFP 30-DMA-284-11 shall include a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g). d. “Privacy and Security Rules” shall mean the Standards for Privacy of Individually Identifiable Health Information and the Security Standards for the Protection of Electronic Protected Health Information set out in 45 CFR part 160 and part 164, subparts A and E. e. “Protected Health Information” shall have the same meaning as the term “protected health information” in 45 CFR 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity. f. “Required By Law” shall have the same meaning as the term “required by law” in 45 CFR 164.103. g. “Secretary” shall mean the Secretary of the United States Department of Health and Human Services or his designee. h. “Security Incident” shall have the same meaning as the term “security incident” in 45 CFR 164.304. i. Unless otherwise defined in this Agreement, terms used herein shall have the same meaning as those terms have in the Privacy and Security Rules. 3. OBLIGATIONS OF BUSINESS ASSOCIATE a. Business Associate agrees to not use or disclose electronic protected health information or other protected health information other than as permitted or required by this Agreement or as required by law. b. Business Associate agrees to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information and other protected health information that it creates, receives, maintains, or transmits on behalf of Covered Entity, as required by the Privacy and Security Rules. c. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of electronic protected health information or other protected health information by Business Associate in violation of the requirements of this Agreement. d. Business Associate agrees to report to Covered Entity (i) any use or disclosure of electronic protected health information or other protected health information not provided for by this Agreement of which it becomes aware and (ii) any security incident of which it becomes aware. e. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides electronic protected health information and/or other protected health information received from, or created or received by Business Associate on behalf of Covered Entity (i) agrees to be bound by the same restrictions and conditions that apply Page 25 of 44 RFP 30-DMA-284-11 through this Agreement to Business Associate with respect to such information, and (ii) agrees to implement reasonable and appropriate safeguards to protect such information. f. Business Associate agrees to provide access, at the request of Covered Entity, to electronic protected health information and other protected health information in a Designated Record Set to Covered Entity or, as directed by Covered Entity, to an individual in order to meet the requirements under 45 CFR 164.524. g. Business Associate agrees, at the request of Covered Entity, to make any amendment(s) to electronic protected health information and other protected health information in a Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR 164.526. h. Unless otherwise prohibited by law, Business Associate agrees to make internal practices, books, and records, including policies and procedures concerning electronic protected health information and other protected health information, relating to the use and disclosure of electronic protected health information and other protected health information received from, or created or received by Business Associate on behalf of, Covered Entity available to the Covered Entity, or to the Secretary, in a time and manner designated by the Secretary, for purposes of the Secretary determining Covered Entity's compliance with the Privacy and Security Rules. i. Business Associate agrees to document such disclosures of electronic protected health information and other protected health information related to such disclosures as would be required for Covered Entity to respond to a request by an individual for an accounting of disclosures of electronic protected health information and other protected health information in accordance with 45 CFR 164.528, and to provide this information to Covered Entity or an individual to permit such a response. 4. PERMITTED USES AND DISCLOSURES a. Except as otherwise limited in this Agreement or by other applicable law or agreement, if the Contract permits, Business Associate may use or disclose electronic protected health information and other protected health information to perform functions, activities, or services for, or on behalf of, Covered Entity as specified in the Contract, provided that such use or disclosure: (1) would not violate the Privacy and Security Rules if done by Covered Entity; or (2) would not violate the minimum necessary policies and procedures of the Covered Entity. b. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the Contract permits, Business Associate may use electronic protected health information and other protected health information as necessary for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate. c. Except as otherwise limited in this Agreement or by other applicable law or agreements, Page 26 of 44 RFP 30-DMA-284-11 if the Contract permits, Business Associate may disclose electronic protected health information and other protected health information for the proper management and administration of the Business Associate, provided that: (1) disclosures are required by law; or (2) Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and will be used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached. d. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the Contract permits, Business Associate may use electronic protected health information and other protected health information to provide data aggregation services to Covered Entity as permitted by 45 CFR 164.504(e)(2)(i)(B). e. Notwithstanding the foregoing provisions, Business Associate may not use or disclose electronic protected health information or other protected health information if the use or disclosure would violate any term of the Contract or other applicable law or agreements. 5. TERM AND TERMINATION a. Term. This Agreement shall be effective as of the effective date stated above and shall terminate when the Contract terminates. b. Termination for Cause. Upon Covered Entity's knowledge of a material breach by Business Associate, Covered Entity may, at its option: (1) Provide an opportunity for Business Associate to cure the breach or end the violation, and terminate this Agreement and services provided by Business Associate, to the extent permissible by law, if Business Associate does not cure the breach or end the violation within the time specified by Covered Entity; (2) Immediately terminate this Agreement and services provided by Business Associate, to the extent permissible by law; or (3) If neither termination nor cure is feasible, report the violation to the Secretary as provided in the Privacy and Security Rules. c. Effect of Termination. (1) Except as provided in paragraph (2) of this section or in the Contract or by other applicable law or agreements, upon termination of this Agreement and services provided by Business Associate, for any reason, Business Associate shall return or destroy all electronic protected health information and other protected health information received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to electronic protected health information and other protected health information that is in the Page 27 of 44 RFP 30-DMA-284-11 possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the electronic protected health information or other protected health information. (2) In the event that Business Associate determines that returning or destroying the electronic protected health information or other protected health information is not feasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction not feasible. Business Associate shall extend the protections of this Agreement to such electronic protected health information and other protected health information and limit further uses and disclosures of such electronic protected health information and other protected health information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such electronic protected health information and other protected health information. 6. GENERAL TERMS AND CONDITIONS a. This Agreement amends and is part of the Contract. b. Except as provided in this Agreement, all terms and conditions of the Contract shall remain in force and shall apply to this Agreement as if set forth fully herein. c. In the event of a conflict in terms between this Agreement and the Contract, the interpretation that is in accordance with the Privacy and Security Rules shall prevail. In the event that a conflict then remains, the Contract terms shall prevail so long as they are in accordance with the Privacy and Security Rules. d. A breach of this Agreement by Business Associate shall be considered sufficient basis for Covered Entity to terminate the Contract for cause. ________________________________________________________________________________ Offeror’s/Business Associate’s Name ________________________________________________________________________________ Signature Date ________________________________________________________________________________ Printed Name Title This Agreement Must Be Signed By The Same Individual Who Signed The Proposal Execution Page Page 28 of 44 RFP 30-DMA-284-11 ATTACHMENT C Cost Proposal To Review Medical Records and Render a Determination $___________ /per completed review X 7683 = A To Participate in Appeals/ Hearings $ ___________ /per hour X 19 = B Total A: $____________ Total B: $____________ Grand Total for Each Contract Year $____________ The Division shall perform all mathematical calculations as follows: Multiply each cost submitted by the Offeror by it's appropriate multiplier (Multipliers are based on services provided in previous contract years and average annual increase in services Sum A and B resulting in a Grand Total. NOTE: The multipliers used during this calculation are to facilitate the State’s evaluation of the competing cost proposals. They are not a guarantee of business volume. The Division will determine low cost by normalizing the scores as follows: The proposal with the lowest cost (lowest Grand Total) will receive a sore of 300. Other proposals will be assigned a portion of the maximum score using the formula: 300 x (lowest cost proposal/cost proposal being evaluated). Signature Date Printed Name Title [The Cost Proposal Must Be Signed By the Same Individual Who Signed The Proposal Execution Page] Instructions 1. Enter your Cost Proposal on this form. Do not use any other form. Use of another form may be cause for the Offeror’s proposal to be rejected. 2. The cost to the State quoted above must cover all of the Offeror’s costs. No other payments will be made by the State for the services rendered. 3. All costs quoted in your Cost Proposal must be firm and fixed for the duration of the contract, which could last as long as three years if the State exercises both one-year options. Page 29 of 44 RFP 30-DMA-284-11 4. DMA may ask for clarification during the evaluation period but it is not required to do so. Cost Proposals that are incomplete or that contain significant inconsistencies may be rejected by the State without any request for clarification. 5. Unsigned Cost Proposals will be rejected by the State. Page 30 of 44 RFP 30-DMA-284-11 ATTACHMENT D Federal Employer Identification Number Vendor Name: _______________________________ ATTENTION: Federal Employer Identification Number of alternate identification number (e.g., Social Security Number) is used for internal processing, including proposal tabulation. Enter ID number here: _____________________________ Pursuant to N.C.G.S. 132-1.10(b) this identification number shall not be released to the public. This page will be removed and shredded, or otherwise kept confidential prior to the procurement file being made available for public inspection. THIS PAGE IS TO BE FILLED OUT AND RETURNED WITH YOUR PROPOSAL. FAILURE TO DO SO MAY SUBJECT YOUR PROPOSAL TO REJECTION. Page 31 of 44 RFP 30-DMA-284-11 ATTACHMENT E North Carolina Department Of Health And Human Services Division Of Medical Assistance Certification of Financial Condition Name of Vendor: __________________________________________________________________________ Date RFP Issued: _________________________________________________________________________ The undersigned hereby certifies that: [check all applicable boxes] The Vendor is in sound financial condition and received an unqualified audit opinion for the latest audit of its financial statements. Date of latest audit: __________________________ The Vendor has no outstanding liabilities to the Internal Revenue Service or other government entities. The Vendor is not the subject of any current litigation or findings of noncompliance under federal or state law. The Vendor has not been the subject of any past litigation or findings of any past litigation or findings of noncompliance under federal or state law. He or she is authorized to make the foregoing statements on behalf of the Vendor. If any one or more of the foregoing boxes is NOT checked, please explain the reason in the space below. Attach additional pages if necessary. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________ Signature Date ________________________________________________________________________________________ Printed Name Title [This Certification Must Be Signed By The Same Individual Who Signed The Proposal Execution Page] Page 32 of 44 RFP 30-DMA-284-11 ATTACHMENT F FEDERAL CERTIFICATIONS The undersigned states that: 1. He or she is the duly authorized representative of the Vendor named below; 2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Vendor, as set out herein: a. The Certification Regarding Nondiscrimination; b. The Certification Regarding Drug-Free Workplace Requirements; c. The Certification Regarding Environmental Tobacco Smoke; d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions; and e. The Certification Regarding Lobbying; 3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses at which the contract work will be performed; 4. [Check the applicable statement] He or she has completed the attached Disclosure Of Lobbying Activities because the Vendor has made, or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action; OR He or she has not completed the attached Disclosure Of Lobbying Activities because the Vendor has not made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or employee of any agency, any Member of Congress, any officer or employee of Congress, or any employee of a Member of Congress in connection with a covered Federal action. 5. The Vendor shall require its subcontractors, if any, to make the same certifications and disclosure. ____________________________________________________________________________________________________________ Signature Title ____________________________________________________________________________________________________________ Vendor Date [This Certification Must Be Signed By The Same Individual Who Signed The Proposal Execution Page] ************************************************************************************************************ I. Certification Regarding Nondiscrimination The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or Page 33 of 44 RFP 30-DMA-284-11 financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement. ************************************************************************************************************ II. Certification Regarding Drug-Free Workplace Requirements 1. The Vendor certifies that it will provide a drug-free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the Vendor’s workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing a drug-free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) The Vendor’s policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the agreement, the employee will: (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; (e) Notifying the Department within ten days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction; (f) Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted: (1) taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; and (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). 2. The sites for the performance of work done in connection with the specific agreement are listed below (list all sites; add additional pages if necessary): Street Address No. 1: ________________________________________________________________________________ City, State, Zip Code: __________________________________________________________________________________ Street Address No. 2: ________________________________________________________________________________ City, State, Zip Code: __________________________________________________________________________________ Page 34 of 44 RFP 30-DMA-284-11 3. Vendor will inform the Department of any additional sites for performance of work under this agreement. 4. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination of grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510. ************************************************************************************************************ III. Certification Regarding Environmental Tobacco Smoke Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day and/or the imposition of an administrative compliance order on the responsible entity. The Vendor certifies that it will comply with the requirements of the Act. The Vendor further agrees that it will require the language of this certification be included in any subawards that contain provisions for children's services and that all subgrantees shall certify accordingly. ************************************************************************************************************ IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions Instructions [The phrase "prospective lower tier participant" means the Vendor.] 1. By signing and submitting this document, the prospective lower tier participant is providing the certification set out below. 2. The certification in this clause is a material representation of the fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originate may pursue available remedies, including suspension and/or debarment. 3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended, determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the department or agency with which this transaction originated. 6. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it knows Page 35 of 44 RFP 30-DMA-284-11 that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension, and/or debarment. Certification a. The prospective lower tier participant certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. b. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. ************************************************************************************************************ V. Certification Regarding Lobbying The Vendor certifies, to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form SF-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. 3. The undersigned shall require that the language of this certification be included in the award document for subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) who receive federal funds of $100,000.00 or more and that all subrecipients shall certify and disclose accordingly. 4. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than $100,000.00 for each such failure. ************************************************************************************************************ VI. Disclosure Of Lobbying Activities Instructions This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space Page 36 of 44 RFP 30-DMA-284-11 on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub-award recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in Item 4 checks "Subawardee", then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e.g., Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5. 10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in Item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name and Middle Initial (MI). 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made. 12. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment. 13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted. 15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached. 16. The certifying official shall sign and date the form, print his/her name, title, and telephone number. Page 37 of 44 RFP 30-DMA-284-11 Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348- 0046), Washington, D. C. 20503 Page 38 of 44 RFP 30-DMA-284-11 Disclosure Of Lobbying Activities (Approved by OMB 0344-0046) Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. Bid/offer/application a. initial filing b. grant b. Initial Award b. material change c. cooperative agreement c. Post-Award d. loan For Material Change Only: e. loan guarantee f. loan insurance Year___________ Quarter____________ Date Of Last Report:_________________ 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime: Prime Subawardee Tier (if known) ________________________ Congressional District (if known) _________________________ Congressional District (if known) ________________________ 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number (if applicable) ________________________ 8. Federal Action Number (if known) 9. Award Amount (if known) $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, MI): different from No. 10a.) (last name, first name, MI): (attach Continuation Sheet(s) SF-LLL-A, if necessary) (attach Continuation Sheet(s) SF-LLL-A, if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ actual planned a. retainer b. one-time fee 12. Form of Payment (check all that apply): c. commission d. contingent fee a. cash e. deferred b. In-kind; specify: Nature f. other; specify: _____________________________ Value 14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF-LLL-A, if necessary): 15. Continuation Sheet(s) SF-LLL-A attached: Yes No 16. Information requested through this form is authorized by Signature: title 31 U. S. C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which Print Name: reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required Title: ______________________________________________ pursuant to 31 U. S. C. 1352. This information will be reported to the Congress semi-annually and will be Telephone No: Date: available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL Page 39 of 44 RFP 30-DMA-284-11 Attachment G North Carolina Department of Health and Human Services Division of Medical Assistance Conflict of Interest Policy for Private Not-for-Profit Agencies Agency staff persons are obligated to always act in the best interest of the organization. This obligation requires that any employee, in the performance of Agency duties, seek only the furtherance of the Agency mission. At all times, employees are prohibited from using their job title, the organization's name or property, for private profit or benefit. (1) The officers, employees, or agents of the Agency should neither solicit nor accept gratuities, favors, or anything of monetary value from contractors/vendors. This is not intended to preclude bona-fide Agency fund raising-activities. (2) No officer, employee, or agent of the Agency shall participate in the selection, award, or administration of a purchase or contract with a vendor where, to his knowledge, any of the following has a financial interest in that purchase or contract: (a) The officer, employee, or agent; (b) Any member of their immediate family; (c) Their partner; (d) An organization in which any of the above is an officer, director, or employee; (e) A person or organization with whom any of the above individuals is negotiating or has any arrangement concerning prospective employment. (3) Disclosure. Any possible conflict of interest shall be disclosed by the person or persons concerned. (4) Board Action. When a conflict of interest is relevant to a matter requiring action by the Board of Trustees, the interested person(s) shall call it to the attention of the Board of Trustees and said person(s) shall not vote on the matter. In addition, the person(s) shall not participate in the final deliberation or decision regarding the matter under consideration and shall retire from the room during the vote of the Board of Trustees. When there is a doubt as to whether a conflict exists, the matter shall be resolved by vote of the Board of Trustees, excluding the person(s) concerning whose situation the doubt has arisen. (5) Record of Conflict. The official minutes of the Board of Trustees shall reflect that the conflict of interest was disclosed and the interested person(s) was (were) not present during the final discussion or vote and did not vote on the matter. ________________________________________________________________________________ Official Agency Title _______________________________________ _____________________________________ Signature of Agency Official Notary Public Signature and Official Seal _______________________________________ _____________________________________ Date Commission Expiration Date Page 40 of 44 RFP 30-DMA-284-11 ATTACHMENT H Certification of Compliance With Executive Order # 24 The undersigned certifies, to the best of his or her knowledge and belief, that: By Executive Order 24, issued by Governor Perdue, and N.C.G.S.§ 133-32, it is unlawful for any vendor or contractor (i.e. architect, bidder, contractor, construction manager, design professional, engineer, landlord, offeror, seller, subcontractor, supplier, or vendor), to make gifts or to give favors to any State employee of the Governor’s Cabinet Agencies (i.e., Administration, Commerce, Correction, Crime Control and Public Safety, Cultural Resources, Environment and Natural Resources, Health and Human Services, Juvenile Justice and Delinquency Prevention, Revenue, Transportation, and the Office of the Governor). This prohibition covers those vendors and contractors who: (1) have a contract with a governmental agency; or (2) have performed under such a contract within the past year; or (3) anticipate bidding on such a contract in the future. For additional information regarding the specific requirements and exemptions, vendors and contractors are encouraged to review Executive Order 24 and G.S. § 133-32. The undersigned shall require that the language of this certification be included in the award documents for all sub- awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-contractors shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State Employee of any gift from anyone with a contract with the State, or from any person seeking to do business with the State. By execution of this Attachment and submitting a bid in response to the accompanying solicitation, you attest, for your entire organization and its employees or agents, that you are not aware that any such gift has been offered, accepted, or promised by any employees of your organization. TYPE OR PRINT NAME & TITLE OF PERSON SIGNING: E-MAIL: AUTHORIZED SIGNATURE: DATE: THIS PAGE MUST BE SIGNED AND DATED AND SUBMITTED WITH YOUR PROPOSAL Unsigned proposals will not be considered Page 41 of 44 RFP 30-DMA-284-11 ATTACHMENT I Administrative Rule Governing Award Protests 01 NCAC 05B .1519 PROTEST PROCEDURES (a) To ensure fairness to all offerors and to promote open competition, agencies and the Division of Purchase and Contract shall actively follow-up and be consistent in responding to an offeror's protest over contract awards. (b) This Rule applies only to contracts with an actual or estimated dollar value over ten thousand dollars ($10,000). Agencies may establish procedures to handle an offeror's concerns for contracts with less dollar value. (c) When an offeror wants to protest a contract awarded by an agency over ten thousand dollars ($10,000) in value, the agency and the offeror shall comply with the following: (1) The offeror shall submit a written request for a protest meeting to the agency's executive officer which shall be received by the agency's executive officer's office within thirty (30) consecutive calendar days from the date of the contract award. The executive officer shall furnish a copy of this letter to the SPO within five consecutive calendar days of receipt. The offeror's letter shall contain specific reasons and any supporting documentation for why it has a concern with the award. If the letter does not contain this information, or if the executive officer determines that a meeting would serve no purpose, then the executive officer may, within ten (10) consecutive calendar days from the date of receipt of the letter, respond in writing to the offeror and refuse the protest meeting request. A copy of the executive officer's letter shall be forwarded to the SPO. (2) If the protest meeting is granted, the executive officer shall attempt to schedule the meeting within thirty (30) consecutive calendar days after receipt of the letter, or as soon as possible thereafter. Within ten (10) consecutive calendar days from the date of the protest meeting, the executive officer shall respond to the offeror in writing with the executive officer's decision. A copy of the executive officer's letter shall be forwarded to the SPO. (3) The agency shall notify the SPO in writing of any further administrative or judicial review of the contract award. (4) The executive officer may appoint a designee to act on the executive officer's behalf under this Rule. (d) When an offeror wants to protest a contract awarded by the Secretary over ten thousand dollars ($10,000) in value, the SPO and the offeror shall comply with the following: (1) The offeror shall submit a written request for a protest meeting to the SPO which shall be received by the Division within thirty (30) consecutive calendar days from the date of the contract award. The offeror's letter shall contain specific reasons and any supporting documentation for why it has a concern with the award. If the letter does not contain this information, or if the SPO determines that a meeting would serve no purpose, and then the SPO may, within ten (10) consecutive calendar days from the date of receipt of the letter, respond in writing to the offeror and refuse the protest meeting request. (2) If the protest meeting is granted, the SPO shall attempt to schedule the meeting within thirty (30) consecutive calendar days after receipt of the letter, or as soon as possible thereafter. Within ten (10) consecutive calendar days from the date of the protest meeting, the SPO shall respond to the offeror in writing with the SPO's decision. History Note: Authority G.S. 150B-2; 150B-22; 150B-23; 143-53; Eff. February 1, 1996; Temporary Amendment Eff. February 15, 1998; Amended Eff. April 1, 1999 Page 42 of 44 RFP 30-DMA-284-11 APPENDIX I EMERGENCY MEDICAL SERVICES REQUEST FOR MISSING INFORMATION Date: _____________ County Department of Social Services Attention: Re: After careful review of the submitted information, we have found that items are missing from the above referenced medical record. Please contact the appropriate provider(s) to obtain the following items and return them to____________________________________ with this sheet: □ Discharge Summary □ History and Physical □ Emergency Room Records/Triage □ Consultation Record/Operative Report □ Physician’s Progress Notes □ Physician’s Order Sheets □ Nurse’s Notes □ Death Summary □ Other: After acquiring the needed records, please include this sheet with the requested information and send via fax to ________________________, Attention: Alien Emergency Services Review or mail to the address listed above. Note: Do not Fax records larger than 50 pages. Your assistance in providing the requested information will ensure prompt return of a decision. If you have any questions please call_____________________. This message and accompanying documents are covered by the Electronic Communications Privacy Act, 18 U.S.C. §§ 2510-2521, and contain information intended for the specified individual(s) only. This information is confidential. If you are not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and that any review, dissemination, copying, or the taking of any action based on the contents of this information is strictly prohibited. If you have received this communication in error, please notify us immediately. Page 43 of 44 RFP 30-DMA-284-11 Revised 05/2011 DMA-5134 APPENDIX II DATE(S) OF EMERGENCY SERVICES REQUESTED FOR AN ALIEN TO: ________________________________________________________ FROM: __________________________________County Department of Social Services RE: Emergency Services for an Alien Date: Applicant's Name: ___________________________________ Aid Program/Category: ______________________ MID ______________________________________________ Sex: _________ DOB: ______________________ Application Due Date (45th/90th Day): _____________________________________________________________ The individual named above has applied for Medicaid payment for emergency care as defined in Alien Requirements, MA- 2504/3330, of the Medicaid Eligibility Manual. The following dates of service are requested, and I certify that I am enclosing appropriate medical records to cover each date requested: ________________________________________ _____________________________________________ ________________________________________ _____________________________________________ ________________________________________ _____________________________________________ NOTE: Determination of eligibility cannot be made without the required medical records for the dates of service requested. Do not send medical records for dates other than those indicated. Do not fax records larger than 50 pages. County Contact Person: _____________________________________________________________________ E-Mail Address:___________________________________________________________________________ Telephone No.: ___________________________ Fax No.: ______________________________________ ********************************************************************************** Emergency services approved. To be completed by the medical review staff. Dates: ___/___/___ through ___/___/___ Dates___/___/___through___/___/___ Dates: ___/___/___ through ___/___/___ Dates___/___/___through___/___/___ Comments: ____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ __________________________________________________ Signature of Reviewer Date Page 44 of 44
"STATE OF NORTH CAROLINA"